Principles of Safe Video Consulting in General Practice During COVID-19

Overview

This Guidelines summary covers guidance for safe video consulting in general practice. It includes key principles, general information, and recommendations on conducting safe video consultations. Refer to the full guideline for information on:

• information governance
• communication with colleagues
• medico-legal information
• clinical worries.

Key Principles for Safely Assessing Patients Using a Video Consultation

• Apply your current skills and clinical acumen when consulting remotely. Use the boundaries and thresholds you already use and apply these
• A good history and functional assessment are vital. Consider non-COVID-19 differentials, and the context. Are these new symptoms and signs, or a follow on relating to an established long-term health condition, or wellbeing problem?
• Tools can assist in decision-making but must not overshadow a holistic assessment of the patient
• Look at trends and for signs of deterioration
• Remain professionally curious and vigilant. Consider safeguarding issues and whether you can explore these fully via a remote consultation. Have a very low threshold for converting a remote consultation to a face-to-face assessment if you have concerns. Update your safeguarding policy to cover remote consultations
• Consider how your actions will change your clinical management, e.g. will the patient need escalation regardless of whether they have a face-to-face examination?
• Explicit safety-netting is essential. Consider if the patient requires remote monitoring
• Use colleagues for support, for example, to discuss clinical issues and peer-review decision making
• Signpost patients to patient information to support self-management and safety netting on the NHS website (including access using a virtual assistant or similar devices)
• Non-digital users can be supported to use video technology by a carer, where available, with implied patient consent
• If a patient requires a face-to-face review, e.g. they need a physical examination or are unable to use the technology, this should be arranged at an appropriate healthcare setting and time
• Facilitate effective communication using translation services, where possible, but their availability should not preclude a video consultation if deemed appropriate based on clinical judgement
• Complete a clinical safety risk assessment. Where a video consultation solution has been procured by the CCG this should be carried out by the CCG on behalf of their practices, with individual practices working collaboratively with the local clinical safety officer
• As a consequence of the response to COVID-19, patients may not be accessing health services when they need to, so presentations may be more serious at first contact. Be aware of more vulnerable characteristics where engagement may be delayed.

General Information

The decision to offer a video consultation should be part of the wider system of triage and management offered in your practice and should be based on clinical judgement. There is no need to use video when an online consultation or telephone call is sufficient. Be aware that patients or their relatives may record the video consultation.

See the full guideline for information on information governance, communication, and medico-legal issues.

Consent

• The consent of the patient is implied by them accepting the invitation and entering the video consultation. It is good practice to confirm and record their consent for a video consultation and confirm whether the consultation is being audio or video recorded
• Be mindful of the following issues:
  • the limitations of a remote assessment, whether it is likely to provide sufficient information to make the clinical judgement in question or whether a more extensive assessment of the patient and/or investigation may be indicated
  • whether the patient feels comfortable with a remote assessment (including concerns about security or privacy) or whether they would prefer a face-to-face consultation
  • the trade-off for a patient between attending in person and staying at home, where the advantages of remote consulting may outweigh limitations for some patients during the COVID-19 pandemic
  • the nature of the examination and the examination setting (for example, traditionally it is unusual for a clinician to undertake an examination in this way, the patient may want to relocate to another room if there are other family members in the vicinity). It is therefore important to ensure the consent of the patient is tailored to the specific circumstances of the remote examination
  • the need for privacy around the practitioner’s screen to ensure that no one can view or overhear the call without the consent of the patient
  • if it is not possible to adequately assess a patient’s condition in this way, clinicians should consider if a face-to-face consultation to examine the patient is necessary, or signpost to other services where appropriate
  • with the consent of the patient (or someone who has the legal authority to act on the patient’s behalf), or where a decision to proceed with an examination is made in the patient’s best interests, you should have an appropriately trained chaperone present for any situation where you would do so in a face to face consultation. If a chaperone is not available (for example because you are remote working) or declined by the patient, use your professional judgement and carefully consider whether a remote examination method should proceed
  • be aware that patients or their relatives may record the video consultation. If you are concerned about how the recording may be used carefully consider whether a remote examination method should proceed.

See the full guideline for more information about what to do if the patient lacks capacity to consent, including assessing young people under 16.

Remote Examination

• This guidance should be used in conjunction with guidance on how to conduct a video consultation and online consultation (text-based interaction)
• Provide guidance for patients on getting set up and having a video consultation including a code of conduct
• All clinicians should feel competent and comfortable in the mode of assessment and examination technique
• Triage the patient using an online consultation or telephone call
• If you decide they need a remote examination, where possible carry this out via a video call.

Examinations that May be Perceived to be Intimate

• Remote examinations that are intimate or may be perceived as intimate must be approached with caution
• NHS England has developed detailed guidance with multiple organisations on key considerations and principles for intimate clinical assessments undertaken remotely.

Identity

• Confirm the patient’s identity if they are not known to you, e.g. check name and date of birth
• If you have safeguarding concerns, and the patient is unknown to you, verify their ID, e.g. vouching if you have access to the patient’s clinical record, or by asking for photo ID.

Introduction

• Introduce everyone in the room, even those off camera or confirm with the patient that they (and you) are alone. Follow this with:
  • checking if the patient or anyone else is recording the consultation
  • ensuring you use a private, well-lit room and ask the patient to do the same. You should safeguard personal/confidential patient information in the same way you would with any other consultation
  • taking the patient’s phone number in case the video link fails
• If the connection or video quality is poor, ask the patient to re-book or conduct a phone or face to face consultation as it is possible you could miss something due to technical interference.

Starting the Examination

Setting Up

• Your initial focus should be on the camera position in order that the patient sees your full face and you are in focus. Confirm the patient’s location in case you need to send help: they may not be at their home address. Then explain the nature and extent of the examination and seek verbal consent
• When talking, look at the camera
• When listening continue to look at the camera and screen
• Assess the patient. This will involve breaking eye contact. Signpost what you are doing when you need to look away to avoid looking uninterested. Preface with a comment such as ‘I’m going to take a closer look at your breathing now’.

Visually Assess the Patient

• Assess their demeanour, behaviour, skin colour (including mottling), temperature, posture, hydration status and sweating
• Assess surroundings
• Do they sound or look very unwell?
• Assess their breathing—are they too breathless to talk?
• Are they in distress or pain?
• Do they look upset?
• Are they lying in bed or are they up and about?
• Is there any obvious pathology, such as a wound, not moving a limb, facial droop, tremor, slurred speech, etc.

Go Straight to Key Clinical Questions

• Check red flags for COVID-19 and non-COVID-19
• Ask why the patient has chosen to consult now (explore soft signs such as ‘gut feel’ and concerns)
• Check for signs of deterioration (symptoms, signs and function)
• Ask what the patient wants out of the consultation
• Check their medical record for risk status
• Be clear and direct with questions and explicit about concerns
• Check you have the whole picture.

Initial Assessment—Abnormal Vital Signs?

1. Ask the patient to tap out their pulse and count the pulse rate (or show the patient how to take their pulse rate)
2. Ask the patient to place their hand on their chest making it easier to see the chest rise and fall and count the respiratory rate. Look at use of accessory muscles. Listen for stridor, wheeze, grunting, hoarseness of voice
3. Do they feel dizzy or light-headed when they get up from lying down? (Low blood pressure)
4. Are they more muddled than normal? Ask someone who knows them well if they are behaving differently? Do they seem agitated?
5. Are they passing urine normally?
6. If they have a fever, how high and for how many days? (COVID-19 fever is typically >38.0 and persists beyond 5 days). Are they shivering?
7. If they are diabetic, what is their capillary blood sugar? Do they have home ketostix or home dipsticks—what does the urine analysis show?
8. Ask the patient (or the patient’s carer) to feel the patient’s hands and describe how they feel—do they feel cold (but are warm centrally)?

Consider the patient’s age and medications—a patient can be sick with normal vital signs. Look out for compensation, for example, respiratory compensation for metabolic acidosis, or a blunted response to illness, for example, beta blockers blunting the tachycardic response to sepsis.

Family input: has there been a change from baseline?

Trends: has there been a deterioration in the patient’s observations or symptoms?

Is the patient at high risk of deteriorating quickly?

Is the patient able to take their medications? Consider watching them take their medication or drink a glass of water to check they can swallow and co-ordinate an action if concerned.

Taking Observations

Home Monitoring Devices

• Does the patient have access to a home self-monitoring device? (thermometer, O₂ sats monitor, BP machine, peak flow meter, urine dipsticks, weighing scales)
• Are they familiar with how to use it?
• Guide the patient in taking their observations using their home self-monitoring device(s) over the video call
• Be aware that the quality of a patient’s home device may not be the same as those used in clinical practice and it may not have been calibrated
• Exertion tests: An exertional desaturation test should be used with clinical judgement, and only on patients whose resting oximetry reading is 96% or above, unless they are in a supervised care setting. It should be terminated if the patient experiences adverse effects
• The 1-minute sit-to-stand test (patient goes from sitting to standing as many times as they can) has been validated; the unvalidated 40-step test (take 40 steps on a flat surface) is in widespread use. These tests are likely to be specific but not sensitive (i.e. a positive test is serious cause for concern, but a negative test should not necessarily reassure)
• A 3% drop in pulse oximeter reading on exercise is a serious cause for concern in COVID-19, however even a small desaturation on exercise should alert the clinician. Results should be interpreted as part of a wider holistic assessment of the patient. An approved and tested medical-grade oximeter should be used.

Smartphone Apps—Current Evidence

• Should smartphone apps be used as oximeters? Answer: no
• There is no evidence on home monitoring of respiratory rate. If considering the use of apps to monitor observations, only use those that are clinically validated, assured and have been approved as diagnostic medical devices.

Solution if Patients Do Not Have Access to a Home Monitoring Device

• Ambulatory patients: Hot Hub testing on site, either via a pod, in clinic or with patients waiting in cars, in a drive-through type model where appropriate
• Housebound patients: ‘WhileUWait’ home test which is where NHS volunteers at each GP surgery take equipment to the patient’s home to enable the patient to self-monitor from home, with appropriate personal protective equipment (PPE)/training if necessary
• Care and nursing homes to have equipment on site with staff trained to take the measurement and decontaminate equipment, relaying the measurements in a reliable way without interpretation for a specific patient
• Refer to the full guideline for advice on specific clinical worries, including:
  • acute abdomen
  • acute shortness of breath (including on exertion where not normal for the patient)
  • impairment (musculoskeletal or neurological)
  • wound, skin rash or lumps
  • mental state
  • children, including tonsillar examination
  • COVID-19.

Safety Netting

• Be particularly careful to summarise key points and explain next steps in language that will be clear to the patient:
  • explicitly check understanding
  • provide clear safety netting instructions
  • actively signpost for support, e.g. to social prescribing link workers
  • explain what happens next and what to expect
• Decide in what circumstances patients will be followed up with a practice-initiated phone or video call, e.g. if frail/alone and high risk of deterioration; and where patients will be given clear directions to contact the practice if symptoms deteriorate, e.g. if supported and able to do so. Patients should be clear on what to do if they cannot contact the practice and their symptoms deteriorate
• Think about which patients can use online consultations or messaging for follow-up (consider scheduling a diary entry as a safety net)
• Consider setting up a scheduled ‘check in’ via a message (often a text message) to enable virtual monitoring, where the patient is sent a brief templated questionnaire and reports back on their symptoms, particularly as part of COVID-19 remote monitoring
• Use text or online messaging to send links to advice on the NHS website or patient information leaflets. Use pre-set messages that can be personalised to save time. Advise patients to use an account and/or device which is private to maintain confidentiality. Check with the patient there are no safety concerns.

Documentation

• Make contemporaneous written records in the patient’s medical records, as you would in a standard consultation
• Do not record the video or audio of the consultation unless there is a specific reason to do so, and there is explicit and informed consent from the patient, document these discussions and decisions in the clinical record.